Aim

To determine mortality and outcomes of patients diagnosed with fracture-related infections (FRIs).

Abstract

Introduction

Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain.

A patient in his thirties developed synovitis with grade 4 chondrolysis and a stiff knee with a fixed flexion deformity between three and six years following PLC and PCL reconstruction using LARS (Ligament Augmentation and Reconstruction System, Corin). There was histologic evidence of foreign body reaction, the knee was painful, swollen and stiff.

We did not use any further LARS ligaments for soft tissue reconstructions of the kneein our practice. We commenced a recall programme for all 83 patients patients who underwent a soft tissue knee reconstruction using LARS. Of those contacted, 41 replied (49%) and 16 patients had symptoms (19%) and were investigated further with XRay, MRI and arthroscopy as indicated.

We discovered a total of five patients had histologically proven synovitis with foreign body reactions (6%), three of whom had life-changing symptomatic pain, swelling and stiffness with degenerate changes (3.6%). These patients had undergone various reconstructions, including a) PLC only, b) ACL and PCL, c) PCL and PLC and d) ACL, PCL and PLC. A further single case of massive bone cyst formation was noted, following PCL reconstruction using LARS (1.2%).

The study was to ascertain if parents/carers could be effective screeners in the detection of infant hip dysplasia.

Infants have been screened for developmental hip dysplasia (DDH) since the late 1960's. The recognition of the importance for early identification of the condition has been well documented. However, the changes to the national screening programme in 2008 have reduced the surveillance of DDH following the removal of the 8 month infant hip check, leaving only the 6–8 week hip check as standard.

A self-check guide for DDH has been developed to enlist parents as screeners for the condition. The guide highlights common signs used to alert to the possibility of hip dysplasia or dislocation. The guide was disseminated by the Royal Berkshire Hospital NHS Trust between 2008 – 2013 within West Berkshire through the maternity services and Health Centres. The guide provided parents with information on classic signs associated with DDH which they were asked to check for.

Of those infants referred to our specialist clinic as a result of parental screening, 73% were “abnormal” of these 33% went on to treatment with splintage. The mean age of these infants was 5.36 months. 20% of positive findings were in infants aged 7 month or over at the time seen. None went on to open surgery. These patients represented between 5 and 10% of our overall group of DDH positive patients. If left undiagnosed, they may have gone on to late presentation of hip dislocation requiring surgery as a child or undiagnosed acetabular dysplasia and possible surgical treatment in relatively early adult life.

Therefore we concluded that given the right guidance parents/carers would be ideal screeners to assist in detecting possible later presenting DDH in their baby.

Recurrent patella dislocation is a well-recognized complication after primary dislocation of the patellofemoral joint. We propose that acute surgical management of the injury minimizes this risk.

Between February 2006 and August 2010 47 patients (49 knees) with a mean age of 17.9 (range 12–31) at the time of surgery who sustained a patellofemoral joint dislocation for the first time were treated with an acute repair of the medial patellofemoral ligament.

Patients presenting to our fracture clinic following a primary lateral dislocation of the patella were investigated with an MRI scan and with consent, proceeded to have an examination under anaesthesia and arthroscopy of the injured knee. An easily dislocatable patella in the presence of a confirmed medial patellofemoral ligament rupture was the indication for open repair.

All patients treated surgically were followed up for a period of 24–72 months where the primary outcome measure was further dislocation. An evaluation of symptoms, functional recovery, restoration of range of movement and patient satisfaction was made supported by the Lysholm knee score.

Our results confirm that acute repair of the medial patella femoral ligament in selected patients reduces the risk of further dislocations and results in a overall good functional outcome and patient satisfaction with minimal complications.

Aim

We aim to show that our series of Avon Patellofemoral Joint Replacements (APFJR) with over 5 year follow up, have comparable functional, radiological and revision rate results to other published reports.

This study aims to show that our series of Avon Patellofemoral Joint Replacements (APFJR) with over 5 year follow up, have comparable functional, radiological and revision rate results to other published reports.

Retrospective analysis occurred for all consecutive cases of APFJR from October 1999 and January 2010; all operations were performed by the senior author (AL). Each patient had both clinical and radiological follow up. Patient demographics, pre and post op Oxford Knee scores and complications were all recorded. An independent post-operative radiological review took place to check for loosening and progression of disease. Revision to Total Knee Replacement was taken as the endpoint.

83 consecutive APFJR's were implanted in 56 patients for established isolated patellofemoral arthritis. The average age was 68.2(34-95) with 18 males and 38 females. The mean follow-up was 5.4 years (1.25 to 11). There were 5 revisions with the five-year survival rate being 95.2% (95% confidence interval 88.12% - 99.88%). The median Pre Op Oxford knee score was 17 of 48 points (interquartile range 11 to 21) showed significant improvement when compared to the median Post Op Oxford knee score of 35 (interquartile range 26 to 41). There was one superficial infection, no deep infections and one transient sciatic nerve palsy. These results compare very closely to those in the designing surgeon's series (Ackroyd et al JBJS Br 2007).

These results reveal satisfactory survivorship and functional outcome results in the medium term leading to increased confidence in the use of this patellofemoral arthroplasty.

Aim

To correlate the surgical and MRI findings in acute lateral patellar dislocation and to determine the accuracy of MRI in identifying location of MFPL injury.

The 4th England and Wales NJR showed that 83% of total knee replacements were cemented (47,626 knees). This study aimed to compare modern techniques of cementation of the proximal tibia in an experimental model against tourniquet-less knee replacement surgery with cancellous bone suction and a cement gun.

A metal box was constructed to approximate the proximal tibia and open cell sawbone simulated the tibia with simulated blood flow and bone suction. Each sample was prepared in an identical fashion except for the cementing technique. The techniques compared were of

Tourniquet,

Samples were subsequently sectioned, polished and the cemented area measured using a planimeter.

ANOVA testing demonstrated that the techniques were significantly different (p< 0.0001). Bonferroni Comparison demonstrated that the Exeter technique gave significantly better cement penetration for central and lateral measurements (p< 0.0001 and p< 0.0001) compared to all other methods.

The authors believe that our technique of cementation of the proximal tibia offers an easy and reproducible way of getting good quality cementing of the tibial component in total knee replacement and this is borne out by our experimental model.

This is a study of 24 patients (28 Knees) who underwent acute repair for quadriceps and patellar tendon ruptures using Leeds Keio ligament. Four patients had bilateral quadriceps tendon rupture.

The mean age of patients was 57.4 years (range from 20 to 85 years) with mean follow-up of 20 months (range from 2 months to 3 years). Four patients (6 knees) were lost in follow-up. Knee injury and Osteoarthritis and Outcome Score (KOOS) and Tegner Lysholm Knee Score were used to evaluate the outcome. Sixteen patients had scores of 80 and above in both scoring systems. The mean flexion was 125° and extension lag of 6.6°. The knees were not immobilised after surgery and patients were encouraged to fully weight bear.

One patient had patella fracture secondary to fall although technical error played a part in this. Two patients had bilateral ruptures secondary to fall and one patient had ectopic bone formation. There was no wound infection.

This technique permits immediate mobilisation and full weight bearing of the limb. The early results are promising but long term results are yet to be evaluated.

Introduction: Lengthening for congenital femoral hypoplasia is associated with a significant refracture rate and problems in recovery of knee motion. We present a series of 7 patients where two techniques of lengthening were used and recovery of knee motion compared.

Methods: This is a retrospective study. The outcome of interest was recovery of knee motion. All children were diagnosed to have congenital femoral hypoplasia. In two patients (group A), conventional metaphyseal osteotomies of the femur and tibia, with ankle and knee bridging fixators were applied. In the remaining five (group B), a combination of soft tissue releases, patella ‘capture’, a modified external fixator configuration and early conversion to internal fixation was used. Osteotomies of tibia and femur were performed in the mid-shaft and lengthening progressed at 0.75 mm per day. At 4 months, before regenerate consolidation, both femur and tibia were plated using a submuscular technique. The limb was supported in a cast, which was replaced by a brace at 3 weeks and knee motion exercises started. Lengthening was kept to within 15% in both groups.

Results: Recovery in knee flexion to greater than 90 degrees was accomplished by 4 of the 5 Group B patients by 4 months. One patient failed to attend for physiotherapy and did not progress with knee motion recovery. One patient sustained a fracture proximal to the submuscular plate which needed revision surgery. This did not hinder progress with knee motion recovery. In comparison, patients in group A reached 90 degrees of flexion at 12 months with one patient not exceeding 85 degrees at final follow up and subsequently needing a quadricepsplasty.

Conclusion: Recovery of knee motion may be assisted by soft tissue releases in combination with early conversion to internal fixation.

To share our results following Medial Patellofemoral ligament (MPFL) reconstruction for patellar instability problems using ipsilateral semitendinosus graft anchored to the patella and the medial femoral condyle using biotenodesis screws.

Study design and methods: 35 patients were assessed with a mean follow up of 18 months. All patients had preoperative true lateral knee x-ray, MRI or CT scan to look at trochlear dysplasia and the sulcus tuberosity distance. They all under went MPFL reconstruction using ipsilateral semitendinosus tendon. Two patients had sulcus tuberosity distance greater than 20 mm and they under went a tibial tubercle transfer in addition. Two patients had trochlear dysplasia and hence a trochlearplasty was also done. In skeletally mature patients the hamstrings tendon were anchored to the medial side of the patella in a 5×15mm blind tunnel using biotenodesis screw. This significantly reduces the risk of having patella fracture. All patients were treated by the same surgeon and assessments were performed by a different surgeon based on kujala scores and tegner scores.

Results: Symptom relief was noted in all patients with in 3 months. No patient had patella dislocation or fracture after this procedure. They all had full range of movements and their kujala scores and tegner scores were good to excellent.

Conclusion: MPFL reconstruction using hamstrings tendon anchored to the medial side of the patella and femur using biotenodesis screw gave a good result clinically and is associated with fewer complications including patellar fractures.

This presentation introduces a new tool to be used in the cementing of acetabular components in total hip arthroplasty, the ‘Rim Cutter’. The Rim Cutter is designed to cut a ledge in the rim of the acetabulum into which a flanged cup can be cemented. The flange is trimmed such that it fits precisely into the ledge cut in the acetabulum. We present the in vitro pilot study of the effect of using this tool on the intra-acetabular cement mantle pressure during cup insertion and also the effect on the depth of cement penetration as the cup is inserted. A significant improvement in both cement pressure and cement penetration over conventional flanged and unflanged cups is noted. Improved cement penetration around the rim of the acetabulum in THR has implications for reducing the rate of aseptic loosening. The pilot study also suggests other beneficial features of using the rim cutter such as improved cup centralisation, control of orientation and the prevention of the cup ‘bottoming out’. Further in vivo studies are required to better assess its efficacy.

Background: Patella tendonitis is a condition often found in athletes but is also found in less active patients. It usually responds to conservative management (rest, physiotherapy and anti-inflammatory drugs) but some progress to surgery. A retrospective study was done to look at the results of this surgery in our hospital.

Patients and Methods: From 2001 to 2007, nineteen knees in sixteen patients had open patella tendon decompression. Eleven patients were still involved in sporting activity. All surgery was performed by the same surgeon. The patients were brought back to a clinic for review, examination and VISA score.

Results: All but one patient had an improvement in their pain score. Of the 11 patients that played sport, eight were able to return to sport. Five of these returned to competition.

Five patients would not have the surgery again. Only two of these had still played sport. Three of these had other knee pathology found at arthroscopy.

Conclusions: The results of the surgery were satisfactory, although they were more favourable in the patients that were still involved in sporting activities. The rehabilitation time was much longer than had been expected by most patients.

Isolated patellofemoral arthritis is a common, often debilitating, condition with a number of treatment options available. Avon patellofemoral arthroplasty has been practiced in our district general hospital setting with favourable results. Previous studies have been mainly from the pioneering Bristol centre.

We present the findings of the intermediate results of Avon patellofemoral arthroplasty (PFA) used in the treatment of isolated patellofemoral arthritis.

From 1999 until August 2006, 63 Avon PFA were carried out in 46 patients by a single surgeon. We analysed retrospectively the patient case records and collected data regarding clinical, radiological findings along with patient satisfaction scores using the Oxford knee questionnaire.

45/46 (98%) patients had primary patellofemoral (PF) arthritis. 17/46 (36%) patients suffered from bilateral PF arthritis. The average duration of follow up was 5 years (3 months to 7 years). There were 7 males and 39 females with a median age of 63 years. The average range of movement was 120° (90°–140°). There was no observable radiological loosening. There was a reduction in the Oxford knee score from 33 (21–48) to 17 (1–44). Complications of the procedure included superficial infections (2/46), transient foot drop (1/46), and persistent pain (2/46). Further surgery requiring lateral release was carried out in 2/46 patients. To date, none of the cases have required revision due to progression of arthritis. Patients reported high level of satisfaction following the procedure.

Avon PFA is an effective procedure for the treatment of isolated patellofemoral arthritis, with a low rate of complications and good functional results. To our knowledge, this is the first study in UK outside Bristol, presenting the findings of intermediate results of Avon PFA.

Recent literature suggests MPFL is the primary medial restraint in lateral patellar dislocation and supports acute repair in first lateral dislocations.

Objective: To evaluate the results of patients who underwent acute surgical repair of MPFL in our unit.

Materials and Methods: Nine patients with mean age of 25(12–41) were evaluated in a dedicated clinic. The mean follow-up was 15.7 months (6–22). All patients had MRI scan preoperatively and were operated within two weeks of injury. Patients were evaluated clinically and Kujala and Lysholm scores were recorded.

Results: None of these patients had further dislocations of patella and patellar apprehension test was negative on examination. The mean Kujala score was 78(74–100) and mean Lysholm score was 92(85–100). All patients had returned to sporting activities at clinic review. All but one mentioned that they would choose surgical repair if the injury occurred in the other knee.

Conclusion: Our results confirm in selective patients acute repair of MPFL is the ideal treatment to prevent recurrent dislocations and early return to sports.

Recurrent patellar instability and anterior knee pain is a common problem after patellar dislocation. The medial patellofemoral ligament (MPFL) which contributes 40–80% of the total restraining forces is either attenuated or ruptured in these patients. Various techniques have been described in reconstructing this MPFL using hamstrings tendons. We wish to share our experience in treating these patients using ipsilateral semitendinosus tendon anchored to the medial femoral condyle and medial side of the patella using biotenodesis screws.

Study design and methods: 15 patients were assessed with a mean follow up of 12 months. All patients had pre-operative true lateral knee x-ray, MRI or CT scan to look at trochlear dysplasia and the sulcus tuberosity distance. They all under went MPFL reconstruction using ipsilateral semitendinosus tendon. Two patients had sulcus tuberosity distance greater than 20 mm and they under went a tibial tubercle transfer in addition. Two patients had trochlear dysplasia and hence a trochleaplasty was also done. In skeletally mature patients the hamstrings tendon was anchored to the medial side of the patella in a 5x15mm blind tunnel using biotenodesis screw. This significantly reduces the risk of having patella fracture. In. children the graft was sutures to the soft tissues along the medial side of the patella and the medial femoral condyle. All patients were treated by the same surgeon and assessments were performed by a different surgeon based . on Kujala scores and Tegner scores.

Results: Symptom relief was noted in all patients with in 3 months. No patient had patella dislocation or fracture after this procedure. They all had full range of movements and their Kujala scores and Tegner scores were good to excellent.

Conclusion: MPFL reconstruction using hamstrings tendon anchored to the medial side of the patella and femur using biotenodesis screw gave a good result clinically and is associated with fewer complications including patellar fractures.

Objective: Infants introduced to indoor heated swimming pools in the first year of life show an association with progressive adolescent idiopathic scoliosis (AIS). Similarly control children exposed in this way show an association with vertical spinous process asymmetry. A new method of assessment was used on these controls who were standing in an upright position. Overall, our evidence suggests that indoor heated swimming pools contain a risk factor that predisposes some infants to develop spinal asymmetries years later – progressive AIS in a few and off-vertical spinous process asymmetry in the many. What the risk factor may be and its possible portal of entry into the infant’s body are unknown and possibilities are examined. A subsequent new group of control children confirms the association of indoor heated swimming pools and vertical spinal asymmetry.

Risk factors: An irritant gas trichloramine (nitrogen trichloride) has been found to contaminate the air of indoor-chlorinated pools which Bernard et al link to asthma and chronic airway inflammation. Besides the lungs the skin in infants may provide another portal of entry of any chemical risk factors for spinal asymmetries. In connection with a chemical risk factor Nachemson anecdotally noted the development of scoliosis in salmon fry at a fish farm who were exposed to water contaminated after the re-painting of a water regulating dam.

Environmental epigenomics and disease susceptibility: Barker and his colleagues and others have shown that the origins of important chronic diseases of adult life may lie in foetal responses to the intrauterine environment and in infants to early postnatal life. Currently, there are British and US medical research projects to gather information on how human genes and environment interact over the years to cause disease; the British project is called Biobank. Another aspect concerns disease susceptibility by spotting gene variants in people who already have specific diseases. Do the suspected risk factors of indoor-chlorinated pools for spinal asymmetries need to be included in such studies? Is there potential for prevention?

In our earlier study we found 61% of the controls taken swimming in the first year of life had vertical spinous process asymmetry. In the subsequent smaller study the incidence even higher (83%).

Conclusions:

The evidence reported in our earlier paper suggests that infants introduced to indoor heated swimming pools in the first year of life show an association with spinal asymmetries including progressive AIS and in controls vertical spinous process asymmetry.